GLOBAL PROGRESS REPORT ON
WASH IN HEALTH CARE FACILITIES
Fundamentals first
Global progress report on water, sanitation and hygiene in health care facilities: fundamentals first ISBN 978-92-4-001754-2 (electronic version)
ISBN 978-92-4-001755-9 (print version)
© World Health Organization 2020
Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).
Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”.
Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/).
Suggested citation. Global progress report on water, sanitation and hygiene in health care facilities: fundamentals first.
Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.
Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.
Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing.
Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user.
General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
Terminology used to refer to countries, territories and areas as well as representation of countries, territories and areas, including delimitation of frontiers or boundaries, and any direct or indirect attribution of status in this publication follow exclusively the institutional style and practice of WHO as lead publishing organization and may be at variance with those used by UNICEF.
All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.
Front cover photography credits (from left to right): GettyImages/Ms Yapr; World Vision/Jon Warren.
Edit and design by Inis Communication.
Contents
iv
Forewordv
Acknowledgementsvii
Abbreviationsviii
Glossary1
Global progress at a glance5
Chapter 1. About this report9
Chapter 2. Putting fundamentals first17
Chapter 3. Latest status of WASH services in health care facilities39
Chapter 4. Integration of WASH with energy and health programmes49
Chapter 5. Country and regional progress63
Chapter 6. An investment opportunity71
Chapter 7. Where do we go from here?75
References81
Annex 1. Practical steps to improve WASH in health care facilities88
Annex 2. National water estimates114
Annex 3. Regional and global water estimates124
Annex 4. Methodology used for tracking country progress126
Annex 5. Case studies149
Annex 6. Global health AND CLIMATE campaigns and initiatives:opportunities for impact
151
Annex 7. Suggested actions to achieve the four recommendationsForeword
This global progress report on water, sanitation, hygiene, waste management and cleaning (WASH) in health care facilities comes at an unprecedented moment, when coronavirus disease (COVID-19) is exposing key vulnerabilities in health systems, such as inadequate infection prevention and control.
WASH services in health care facilities, so often taken for granted – or as this report highlights, outright neglected – are needed more than ever to protect vulnerable health workers and patients.
The report identifies major global gaps in WASH services: one third of health care facilities do not have what is needed to clean hands where care is provided;
one in four facilities lack basic water services, and one in 10 have no sanitation services. This means that 1.8 billion people use facilities that lack basic water services and 800 million use facilities with no toilets.
Across the world’s 47 least-developed countries, the problem is even greater: half of health care facilities lack basic water services. Furthermore, the extent of the problem remains hidden because major gaps in data persist, especially on environmental cleaning.
This report also describes global responses. In response to the 2019 World Health Assembly resolution on WASH in health care facilities, data from 47 countries indicates that more than 70%
have conducted related situation analyses, 86% have updated and are implementing standards and 60% are working to incrementally improve infrastructure and operation and maintenance of WASH services. Case studies from 30 countries demonstrate that progress is being propelled by strong national leadership and coordination, use of data to direct resources and action, and the mutual benefits of empowering health workers and communities to develop solutions together.
Despite reported progress, critical gaps remain.
Only one third of countries responding to the World Health Assembly resolution have developed costed roadmaps for action, and just over 10% have integrated WASH indicators into regular national health system monitoring.
This report was launched to coincide with the 2020 International Universal Health Coverage (UHC) Day,
with the theme Protect Everyone. Investments in WASH must be an essential part of UHC for every country. Furthermore, investing in WASH and energy services in health care facilities is one of the core prescriptions for a healthy, green recovery from the COVID-19 pandemic.
Based on the new data in this report, we offer four recommendations to all countries and partners, particularly health and community leaders:
• Implement costed national roadmaps with appropriate financing;
• Monitor and regularly review progress in improving WASH services, practices and the enabling environment;
• Develop capacities of health workforce to sustain WASH services and promote and practice good hygiene; and
• Integrate WASH into regular health sector planning, budgeting, and programming, including COVID-19 response and recovery efforts to deliver quality services.
Implementing these recommendations requires committed and courageous leaders, communities and partners. The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) remain steadfast in supporting these efforts and we call on all countries, partners and individuals to intensify their commitment and related investments.
The world can no longer afford to overlook the fundamentals.
Tedros Adhanom Ghebreyesus, Director-General, World Health Organization
Henrietta H. Fore, Executive Director, United Nations Children’s Fund
Acknowledgements
This report is the result of collaboration between a large number of contributors, reviewers and editors. The development of the report was led by the WHO and UNICEF secretariat: Arabella Hayter, Claire Kilpatrick, Maggie Montgomery and Julie Storr (WHO) and Irene Amongin, Silvia Gaya and Emilia Raila (UNICEF), under the overall direction and guidance of Bruce Gordon and Shamsuzzoha Syed (WHO) and Kelly Ann Naylor (UNICEF).
The authors are grateful to the following organizations and individuals for significant contributions to specific chapters:
Chapter 3: The WHO/UNICEF Joint Monitoring Programme team: Robert Bain; Christie Chatterley;
Rick Johnston; Francesco Mitis; Tom Slaymaker.
Chapter 4: Members of the WHO Taskforce on Quality and those who contributed to the health updates: Lydia Abebe; Benedetta Allegranzi;
Alessandro Cassini; Breeda Hickey; Ivan Ivanov;
Melissa Kleine Bingham; Laura Nic Lochlain; Blerta Maliqi; Nana Mensah Abrampah; Moise Muzigaba;
Margot Nauleau; Stephen Nurse Findlay; Pravarsha Prakash; Tin Tin Stint; Anthony Twyman; Salvatore Vinci; Elena Villalobos Prats; Qingxia Zhong.
Chapter 5: WaterAid, specifically Helen Hamilton, Alison Macintyre and Kyla Smith.
Chapter 6: World Bank, led by Clare Chase; Global Water 2020, specifically Lindsay Denny and Hank Habicht; WaterAid, specifically Fauzia Aliuand, Helen Hamilton, Ellen Greggio, Kyla Smith, George Yorke;
Michael Chaitkin and Samantha McCormick led the costing analysis.
The authors also wish to thank the many individuals who contributed content, helped collate country stories and progress updates and reviewed the draft of the document:
Michelle Adler; Shihab Uddin Ahamad; Laura Alcorn;
Fauzia Alia; Greg Allgood; Onyema Ajuebor; Suraya Amir Husin; Sandrine Andriantsimietry; Jorge
Alvarez-Sala; Frederik Asplund; Naing Aung; A S Nurullah Awal; Shahid Mahbub Awan; Aboubacar Ballo; Hamed Bakir; Kolawole Banwo; Joseph Banzi; Amy Boore; Sory Bouare; John Brogan; Erica Burton; Pierre Carnevale; Sae-Rom Chae; Kangwa Chikuntele; Pamela Chisanga; Chris Cormency;
Tim Davis; Paul Deverill; Indah Deviyanti; Mamadou Diarafa Diallo; Pie Djivo; Quincy T. D’Goll; Therese Dooley; Lobzang Dorji; Edwin Isotu Edeh; Shinee Enkhtsetseg; Ukeme Essien; Sorsa Faltamo Jama;
Jose Gesi; Nkwan Jacob Gobte; Samuel Godfrey;
Faustina Gomez; Giorgia Gon; Fiona Gore;
Wendy Graham; Ellen Greggio; Valentina Grossi;
Sunny Guidotti; Innocent Habimana; Moussa Ag Hamma; Hafizah binti Hasan; Carolyn Herzig;
Breeda Hickey; Alexander von Hildebrand; Mitsuaki Hirai; Mark Hoeke; Erin Hylton; Esmaeil Ibrahim;
Viengsompasong Inthavong; Pam Iyer; Andrea Jones; Dragana Jovanovic; Samuel Kaba; Kristy Kade; Gloria Kafura; Safo Kalandorov; Laxman Kharal; Min Ko Ko; Antoine Kocher; Marcelo Korc;
Waltaji Kutane Terfa; Christopher Lee; Khankrika Lim; Matthew Lozier; Oyuntogos Lkhasuren; Alison Macintyre; Peter Georg L Maes; Bonifacio Magtibay;
Shamsul Mahmud; Pete de Marco; Abdoulaye Mariama Baïssa; Magdalene Matthews Ofori-kuma;
Jolly Ann Maulit; Kaveri Mayra; Guy Mbayo; Evelyn Mere; Didier Monteiro; Annie Msosa; Farzona Mukhitdinova; Sofia Murad; Diriisa Musisi; Mubiana Muyangwa; Jonas Naissem; Alban Nouvellon; Victor Nyamandi; Michele Paba; Molly Patrick; Mohanlal Peiris; Genandrialine Peralta; Malala Ranarison;
Monica Ramos; Hussain Rasheed; Hantanirina Ravaosendrasoa; Nick Rice Chudeau; Bud Rock;
Cipriano do Rosario Pacheco; Mike Paddock; Ute Pieper; Monica Ramos; Bayiha Ruben; Gustavo Saltiel; Channa Sam Ol; Ramon San Pascual; Stephen Sara; Aminatta Sarr; Deepak Saxena; Oliver Schmoll;
Patricia Segurado; Jane Sembuche; Antoinette Shor- Anyawoe; Charles Siachema; Aline Simen Kapeu;
Shivanarain Singh; Susanna Smets; Ruth Stringer;
David Sutherland; Tsedey Tamir; Brenda Tembo;
Lekiley Temeh; Nghia Ton; Alpha Nouhoum Traore;
Julie Truelove; Marta Vargha; Johannah (Yoyo) Wegerdt; Susan Wilburn; Lee (Pamela) Yew Fong;
Osman Yiha; George Yorke.
WHO and UNICEF gratefully acknowledge the financial support provided by:
Agence Francaise de Developpement (AFD);
Australian Department of Foreign Affairs and Trade (DFAT); Conrad N. Hilton Foundation; General Electric (GE) Foundation; Global Environment Facility/United Nations Development Programme;
Netherlands Directorate-General for International Cooperation (DGIS); Japanese International
Cooperation Agency (JICA); Swedish International Development Cooperation Agency (Sida); Swiss Agency for Development and Cooperation (SDC);
United Kingdom Foreign Commonwealth &
Development Office (FCDO); United States Agency for International Development (USAID); and Wallace Genetic Foundation/Water 2020.
The report was edited and designed by Inis Communication.
Abbreviations
ABHR alcohol-based hand rub AMR antimicrobial resistance
CASH Clean and Safe Hospital Initiative CDC Centers for Disease Control and
Prevention
COVID-19 coronavirus disease CSA Centre de Santé Assaini
DHIS-2 District Health Information Software DoH Department of Health
FTF Fast-Track Facility
GFF Global Financing Facility for Women, Children, and Adolescents GLAAS Global Analysis and Assessment of
Sanitation and Drinking Water HEF health equity fund
HEPA Health and Energy Platform of Action
HH4A Hand Hygiene for All
HHSAF hand hygiene self-assessment framework
HMIS health management information system
IADB Inter-American Development Bank IPC infection prevention and control IRENA International Renewable Energy
Agency
JMP WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene LDC least-developed country
LMIC low- and middle-income countries LSHTM London School of Hygiene and
Tropical Medicine
MHM menstrual hygiene management MoH ministry of health
NAP national action plan
NIPH National Institute of Public Health NTD neglected tropical disease OECD Organisation for Economic
Co-operation and Development PAHO Pan American Health Organization PHC primary health care
POP persistent organic pollutant PPE personal protective equipment SARA Service Availability and Readiness
Assessment
SDG Sustainable Development Goal SPA Service Provision Assessment SSP sanitation safety planning UHC universal health coverage UN United Nations
UNDP United Nations Development Programme
UNEP United Nations Environment Program
UNHCR United Nations High Commissioner for Refugees
UNICEF United Nations Children’s Fund USAID United States Agency for
International Development WASH water, sanitation and hygiene WASH FIT Water and sanitation for health
facility improvement tool WHO World Health Organization
Glossary
advanced service levels A more ambitious, higher level of WASH services defined at the national level. May consider further important aspects, including chemical and microbiological water contaminants, including medical-grade water, water efficiency, safe plumbing, climate resilience of water and sanitation services, sustainability (including non-burn waste destruction methods), and safe collection, transport and treatment and the quality of disposed wastewater.
antimicrobial resistance
(AMR) The ability of a microorganism (such as bacteria, viruses and some parasites) to stop an antimicrobial (such as antibiotics, antivirals and antimalarials) from working against it. As a result, standard treatments become ineffective, infections persist and may spread to others. Poor infection control and inadequate sanitary conditions contribute to the spread of AMR.
basic WASH services WHO has a set of minimum, global standards for environmental health in health care facilities (1). Deriving from these standards, a ‘basic’
level of service has been defined and is achieved when key conditions are met in five areas: water, sanitation, hygiene, waste management and environmental cleaning.
climate change Refers to any change in the climate over time, generally decades or longer, whether due to natural variability or as a result of human activity.
climate-resilient health
systems Have the ability to anticipate, respond to, cope with, recover from and adapt to climate-related shocks and stresses, so as to bring sustained improvements in population health, despite an unstable climate.
health care facilities Encompasses all formally recognized facilities that provide health care, including primary (health posts and clinics), secondary and tertiary (district or national hospitals), public and private (including faith-run) and temporary structures designed for emergency contexts (e.g. cholera treatment centres). They may be in urban or rural areas.
health care waste
management Waste generated through health care activities that may be infectious, sharp, non-infectious, chemical, pharmaceutical, radioactive or pathological waste. This waste must be safely segregated, treated and disposed of in line with global standards and international conventions (e.g. the Stockholm and Minimata conventions).
health system Comprises all the organizations, institutions and resources that are devoted to producing actions principally aimed at improving, maintaining or restoring health. Health systems involve numerous stakeholders from individual and community, to government, at local, sub-national and national levels. The health system is recognized by WHO to be made up of six key building blocks: (i) leadership and governance; (ii) health workforce; (iii) health information systems; (iv) essential medical products and technologies; (v) financing; all of which lead to (vi) service delivery. The goal of a health system is to deliver effective preventive and curative health services to the full population, equitably and efficiently, while protecting individuals from catastrophic health care costs.
infection prevention and
control (IPC) broadly defined as the scientific approaches and practical solutions designed to prevent harm caused by infection to patients and health workers associated with delivery of health care. It is a unique specialty encompassing and overlapping with almost every health care programme and system in health care.
Joint Monitoring Programme
(JMP) Responsible for monitoring the 2030 SDG targets 6.1 and 6.2 and supporting global monitoring of other WASH-related SDG targets and indicators. The JMP has produced regular progress reports for WASH in households since 1992 and in the SDGs period expanded to monitor WASH in schools and WASH in health care facilities
least-developed countries Least-developed countries (LDCs) are low-income countries confronting severe structural impediments to sustainable development. There are currently 47 countries on the list of LDCs which is reviewed every three years (2).
multimodal (strategies) Multiple elements, all essential and complementary, must be put in place as part of interventions to achieve outcome improvements and optimal behavioural change (e.g. hand hygiene). It comprises system change, training and education, monitoring and feedback, reminders and communications and culture change.
national action plan (NAP) Following a Resolution on AMR in 2015, the World Health Assembly urged all Member States to develop and have in place by 2017, national action plans on AMR that are aligned with the objectives of the global action plan.
Practical steps A set of eight actions, designed to be undertaken by countries to improve WASH in health care facilities. Some are undertaken at the national level and some at the sub-national or facility level. Some may apply to all levels.
They may occur simultaneously or in a linear fashion.
primary health care (PHC) Where patients generally first engage with the health system. Primary care facilities have a broad range of available technology and services that vary with human resource models and their related competencies. These facilities range from more basic health posts to comprehensive primary care centres.
quality of care Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with evidence-based professional knowledge. This definition of quality of care spans promotion, prevention, treatment, rehabilitation and palliation, and implies that quality of care can be measured and continuously improved through the provision of evidence-based care that takes into consideration the needs and preferences of service users – patients, families and communities.
The Network for Improving Quality of Care for Maternal, Newborn and Child Health (Quality of Care Network)
A broad partnership of committed governments, implementation partners and funding agencies working to ensure that every pregnant woman, newborn and child receives good quality care with equity and dignity (hence also known as the QED Network). The goals of the network are to halve maternal and newborn deaths and stillbirths in health facilities by 2022 and to improve patients’ experience of care in participating health facilities in network countries. As well as a vehicle for learning and exchange the network presents an opportunity to embed WASH as part of quality improvement.
SDG regions Reporting of data and/or progress towards the Sustainable Development Goals (SDGs) is presented worldwide according to various regional groups.
The country groupings are based on the geographic regions defined under the Standard Country or Area Codes for Statistical Use (known as ‘M49’) of the United Nations Statistics Division (3).
service ladders Set by the WHO/UNICEF JMP, multi-level service ladders allow for progressive realization of the SDG criteria, enabling countries at different stages of development to track and compare progress. Separate ladders are proposed for each indicator. The core service ladders include three levels: no service, limited service and basic service.
Small Island Developing
States Small Island Developing States (SIDS) are a distinct group of 38 UN Member States and 20 Non-UN Members/Associate Members of United Nations regional commissions that face unique social, economic and environmental vulnerabilities (4).
universal health coverage
(UHC) Means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care. Without WASH services, the goal of UHC cannot be achieved.
WASH in health care facilities The provision of water, sanitation, health care waste management, hygiene and environmental cleaning infrastructure and services across all parts of a facility.
WASH practices Specific IPC behaviour practices including regular handwashing by care providers, care-seekers and their families at key moments. It also includes regular environmental cleaning of surfaces, floors, and walls in care areas, toilets and showers, as well as laundry, cooking and waiting areas.
WASH FIT A risk-based approach for improving and sustaining water, sanitation, hygiene and health care waste management services in health care facilities, developed by WHO and UNICEF in 2015 and since used in over 30 countries.
References
1. Essential environmental health standards in health care Geneva; World Health Organization; 2008 (https://www.who.int/water_sanitation_health/publications/ehs_hc/en/, accessed 20 November 2020).
2. LDCs at a Glance [website]. New York: United Nations Department of Economic and Social Affairs; 2018 (https://www.un.org/development/desa/dpad/least-developed-country-category/ldcs-at-a-glance.html, accessed 20 November 2020).
3. SDG Indicators. Regional groupings used in Report and Statistical Annex [website]. New York: United Nations Statistics Division (https://unstats.un.org/sdgs/indicators/regional-groups, accessed 20 November 2020).
4. About Small Island Developing States [website]. New York: United Nations Office of the High Representative for the Least Developed Countries, Landlocked Developing Countries and Small Island Developing States;
(https://www.un.org/ohrlls/content/about-small-island-developing-states, accessed 20 November 2020).
Global progress at a glance
a The country progress described in this report is not exhaustive. It focuses on ‘early adopter’ countries and those that have been particularly vocal and ambitious in improving WASH in health care facilities services. Country data will continue to be updated to inform reporting back on this issue at the 2021 World Health Assembly.
Globally, major gaps in basic water, sanitation and hygiene (WASH) services exist in health care facilities.
A quarter of all health care facilities have no basic water services, which means 712 million people have no access to water when they use health care facilities. 10% of health care facilities globally have no sanitation services and one in three do not have adequate facilities to clean hands at the point of care. One in three health care facilities do not segregate waste safely.WASH services are especially deficient in least-developed countries (LDCs).
In LDCs, half of health care facilities lack basic water services and 60% have no sanitation services.
Seven out of ten health care facilities in LDCs lack basic health care waste management services. The economic consequences of coronavirus disease (COVID-19) restriction measures threatens to widen this gap.
Countries are taking steps to address the situation, but progress is variable and insufficient.
Approximately 85% of countries (of the 47a countries included in this report) have conducted situational analyses, 65% have updated and implemented related standards, and over 70% have set up national coordination mechanisms. These actions are broadly on track to meet global targets. Over half of countries have done some health workforce training and mentoring on WASH and hygiene practices, combined with infrastructure improvements. However, less than one third of countries have costed national strategies and just over 10% have included WASH indicators in national health systems monitoring. These indicators demonstrate that many countries are significantly off track to meet global targets for these elements.©MCSP/Karen Kasmauski
©WaterAid/Dennis Lupenga
A global Call to action on WASH in health care facilities, issued by the United Nations (UN) Secretary General in 2018, urged all Member States, UN agencies and partners to commit leadership and resources to addressing this fundamental challenge.
In response, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) developed a corresponding global workplan with targets and metrics to guide action. The two organizations have since released two updates on global data (the latest summarized in the present report) as well as a framework for national and local level action detailing eight ‘practical steps’ that countries might take. The unanimous approval in 2019 of the World Health Assembly Resolution 72.7 on WASH in health care facilities (herein referred to as ‘the Resolution’) committed all countries to act and draws upon the global vision, related metrics and practical steps. The following summary presents current progress towards the global targets and indicators, and helps readers navigate the present report.
TARGET METRICS FOR SUCCESS
*These data are based on the latest estimates from the WHO/UNICEF Joint Monitoring Programme (www.washdata.org) published in 2020, covering the years 2000–2019. The global baseline report published in 2019 presented data from 2000–2016. LDCs are highlighted because they have relatively high data coverage, but also because those living in LDCs are among the most vulnerable.
CURRENT
STATUS IN LEAST DEVELOPED COUNTRIES (2019)*
DATA
AVAILABILITY
2025 2030
At least 80% of facilities
have basic WASH services Universal access to basic WASH services
(Note: These metrics were established as the response to the 2018 UN Secretary General Global Call to Action and to align with SDG 6).
52
countries have basic water data (increase from 38 in 2019)27
countries have basic sanitation data (increase from 18 in 2019)71
countries have hand hygiene data at points of care (increase from 55 in 2019)58
countries have basic health care waste management data (increase from 48 in 2019)50 %
of health care facilities have basic water services
37 %
of health care facilities have basic sanitation services
74 %
of health care facilities have hand hygiene services at points of care
30 %
of health care facilities have basic health care waste management services
SITUATIONAL ANALYSES
By 2021, all countries have completed situational analyses
STANDARDS
By 2021, all countries have standards.
INTEGRATION WITH HEALTH
By 2023, all countries have included WASH in health plans, budgets, and implementation efforts
HEALTH BUDGETS
By 2023, all countries have included WASH in health budgets
COMMITMENTS
By 2020, at least 30 international partners have committed additional resources
Almost 75
%of early adopter countries** are working on or have completed situational analyses (30 countries are conducting situational analyses, of which 11 are completed)
Nearly 100
%of countries** have drafted or are updating standards and 25 have finalized and disseminated
11%
of countries** have included WASH indicators in health systems monitoring
Programmatic integration with health is greater and largely focused on training and assessments.
11
%of countries** have more than 75% of funds needed to reach WASH in health care facility targets.
Over 130
partners have committed resources; 34 made financial commitments in 2019 (totaling US$ 125 million); others allocated human resources, technical and advocacy support.
Examples of situational analyses available at:
www.washinhcf.org/resources/
Examples of country standards available at:
www.washinhcf.org/resources/
Integration detailed through national quality policies, child and maternal health programmes, antimicrobial resistance (AMR) national action plans, cholera control plans and other health programmes
Data from Global Analysis and Assessment of Sanitation and Drinking Water (GLAAS) (2019) (1)
Commitments are detailed on www.washinhcf.org/
commitments-made/ WASH in health care facilities: The 2020 Trailblazers:https:// www.washinhcf.org/ resource/2020-trailblazers- for-wash-in-health-care- facilities/
ACTION NEEDED
• Fill country data gaps, especially on sanitation, health care waste and cleaning• Embed and institutionalize WASH indicators in
health systems monitoring, quality improvement efforts and facility assessments
• All national COVID-19 response and economic recovery plans should include WASH investments
• Leadership, resources and technical committee to carry out analyses, and act on the results and recommendations
• Build technical capacity for updating, disseminating and implementing standards
• Demonstrate incremental approaches to achieve standards
• Integration WASH standards into health regulations
• Adjusting timelines, tools and processes to allow for joint and/or complementary efforts
• Monitoring across quality indicators including WASH inputs, services, patient and staff satisfaction and health outcomes
• Conduct national and facility costing of all WASH elements, including mentoring and training
• Identify national and local budgets and financial bottlenecks, and propose solutions
• Articulate and disseminate value proposition
• Provide costing and financial tools to support regular budgeting and domestic investments
• Follow up with committed organizations to sustain action
LEARN MORE
Chapter 3 Latest WHO/UNICEF JMP global data on WASH services in health care facilities Chapter 6 An investment opportunityChapter 5 Country and regional progress
Annex 1 Practical steps
Chapter 5 Country and regional progress Annex 1 Practical steps
Chapter 4 Integration of WASH with energy and health programmes
Chapter 6 An investment
crisis Chapter 7 Where do we go from here?
METRICS FOR SUCCESS
**This report includes data from 47 early adopter countries who have over the past several years committed resources and taken action to improve WASH in health care facilities. Other countries, globally, may not have made as much progress.
SITUATIONAL ANALYSES
By 2021, all countries have completed situational analyses
STANDARDS
By 2021, all countries have standards.
INTEGRATION WITH HEALTH
By 2023, all countries have included WASH in health plans, budgets, and implementation efforts
HEALTH BUDGETS
By 2023, all countries have included WASH in health budgets
COMMITMENTS
By 2020, at least 30 international partners have committed additional resources
Almost 75
%of early adopter countries** are working on or have completed situational analyses (30 countries are conducting situational analyses, of which 11 are completed)
Nearly 100
%of countries** have drafted or are updating standards and 25 have finalized and disseminated
11%
of countries** have included WASH indicators in health systems monitoring
Programmatic integration with health is greater and largely focused on training and assessments.
11
%of countries** have more than 75% of funds needed to reach WASH in health care facility targets.
Over 130
partners have committed resources; 34 made financial commitments in 2019 (totaling US$ 125 million);
others allocated human resources, technical and advocacy support.
Examples of situational analyses available at:
www.washinhcf.org/resources/
Examples of country standards available at:
www.washinhcf.org/resources/
Integration detailed through national quality policies, child and maternal health programmes, antimicrobial resistance (AMR) national action plans, cholera control plans and other health programmes
Data from Global Analysis and Assessment of Sanitation and Drinking Water (GLAAS) (2019) (1)
Commitments are detailed on www.washinhcf.org/
commitments-made/
WASH in health care facilities: The 2020 Trailblazers:https://
www.washinhcf.org/
resource/2020-trailblazers- for-wash-in-health-care- facilities/
ACTION NEEDED
• Fill country data gaps, especially on sanitation, health care waste and cleaning• Embed and institutionalize WASH indicators in
health systems monitoring, quality improvement efforts and facility assessments
• All national COVID-19 response and economic recovery plans should include WASH investments
• Leadership, resources and technical committee to carry out analyses, and act on the results and recommendations
• Build technical capacity for updating, disseminating and implementing standards
• Demonstrate incremental approaches to achieve standards
• Integration WASH standards into health regulations
• Adjusting timelines, tools and processes to allow for joint and/or complementary efforts
• Monitoring across quality indicators including WASH inputs, services, patient and staff satisfaction and health outcomes
• Conduct national and facility costing of all WASH elements, including mentoring and training
• Identify national and local budgets and financial bottlenecks, and propose solutions
• Articulate and disseminate value proposition
• Provide costing and financial tools to support regular budgeting and domestic investments
• Follow up with committed organizations to sustain action
LEARN MORE
Chapter 3 Latest WHO/UNICEF JMP global data on WASH services in health care facilities Chapter 6 An investment opportunityChapter 5 Country and regional progress
Annex 1 Practical steps
Chapter 5 Country and regional progress Annex 1 Practical steps
Chapter 4 Integration of WASH with energy and health programmes
Chapter 6 An investment
crisis Chapter 7 Where do we go from here?
CHAPTER
1
About this report
PURPOSE
This report provides a comprehensive summary of global progress on improving water, sanitation, hygiene, waste management and environmental cleaning (WASH) in health care facilities and is intended to stimulate solution- driven country and partner actions to further address major gaps. It illustrates how stakeholders in the WASH and health sectors are increasingly working together in specific countries, with the ultimate aim of delivering safe, quality essential health services.
Specifically, the purpose of the report is to:
present the latest data and analysis from the World Health Organization (WHO)/United Nations Children’s Fund (UNICEF) Joint Monitoring Programme on access to coverage of WASH services in health care facilities (Chapter 3);
demonstrate how WASH services in health care facilities are linked to health (Chapter 2) and how these linkages can be operationalized (Chapter 4);
provide an update on country progress in implementing the WHO/UNICEF eight ‘practical steps’ (see Box 1) (2) and other key elements of the 2019 World Health Assembly Resolution on WASH in health care facilities (Chapter 5);
present selected country case studies illustrating bottlenecks, gaps, successful strategies and opportunities for further integrating WASH within health efforts (Chapter 5 and Annex 5);
provide recommendations for addressing gaps, sustaining services and for growing a movement to meet national and global targets (Chapter 7).
BOX 1. A FRAMEWORK FOR NATIONAL AND LOCAL ACTION AND ACCOUNTABILITY: WHO/UNICEF PRACTICAL STEPS
The eight practical steps to improve WASH in health care facilities and advance quality care form the basis and framework for national action and commitments made in the Resolution.
They are a distillation of
‘what works’ from over 50 countries and were developed through a multi-year,
iterative process facilitated by WHO and UNICEF (2).
The steps also are the basis for tracking country progress and reporting on global commitments.
CONDUCT SITUATION ANALYSIS AND ASSESSMENT
1
IMPROVE ANDMAINTAIN INFRASTRUCTURE
4
ENGAGE COMMUNITIES
7
SET TARGETS AND DEFINE ROADMAP
2
MONITOR AND REVIEW DATA
5
CONDUCT OPERATIONALRESEARCH AND SHARE LEARNING
8
ESTABLISH NATIONAL STANDARDS AND ACCOUNTABILITY MECHANISMS
3
DEVELOP HEALTH WORKFORCE
6
Further explanation of the steps and how they are tracked is provided in Annexes 1 and 4.
TARGET AUDIENCES
The report is primarily aimed at three key groups:
National and local governments, national partners and local implementers and advocates for WASH in health facilities.
The global health community, including international partners and investors.
Global WASH and infection prevention and control (IPC) communities, including international partners and investors.
The ultimate success of improving and sustaining WASH in health care facilities requires strong national and local leadership, technical capacity and ongoing investment. The global health community has an important role to play, both in programmatic integration and monitoring, and in allocating resources. In addition, the global WASH community serves a catalytic role, provides technical backstopping and regular global monitoring.
The report is also likely to be of interest to:
climate stakeholders, disaster risk
prevention and preparedness and the global environment community;
civil society organizations;
the energy and infrastructure sectors.
In 2019, all 194 WHO Member States unanimously approved World Health Assembly Resolution 72.7 on WASH in health care facilities (3). The Resolution calls on countries to establish related baselines and set specific targets, embed WASH in key health programmes and budgets, as well as regularly report on progress. The Resolution frames improvement of WASH in health care facilities as a matter of patient safety and an essential prerequisite for infection prevention and for providing equitable and quality health services. Its unanimous endorsement by Member States provided a further mandate to drive national commitments and long-term institutional and systems strengthening. Highlights of the Resolution are shown in Box 2.
©WHO/Arabella Hayter
BOX 2. GLOBAL VISION ON WASH IN HEALTH CARE FACILITIES
Every health care facility has the necessary, functional and sustainable WASH services and practices in order to provide quality essential health services for everyone,
everywhere.
GLOBAL COMMITMENT TO WASH IN HEALTH CARE FACILITIES THROUGH WORLD HEALTH ASSEMBLY RESOLUTION 72.7
194 MEMBER STATES WILL:
•
Conduct assessments on status of WASH and infection prevention and control (IPC).•
Develop and implement national roadmaps.•
Establish and implement minimum standards and integrate into accreditation and regulation systems.•
Include WASH in all health care facility budgets, especially for operation and maintenance.•
Establish strong multisectoral coordination mechanisms.•
Invest in a sufficient and trained health workforce, including health care workers, cleaners and engineers.•
Focus on facilities with the poorest WASH conditions, where maternal and child health services are provided.•
Integrate WASH into health programming, including into nutrition and maternal, child and newborn health within the context of safe, quality and integrated people-centred health services.INTERNATIONAL, REGIONAL AND LOCAL PARTNERS WILL:
•
Raise the profile of safe WASH and IPC in health care facilities, in health strategies and in flexible funding mechanisms.•
Commit to help fill the gap in resource-limited countries by implementing efforts to provide WASH in health facilities.•
Empower communities to participate in the decision-making and reporting concerning more equitable and safe WASH services in health facilities.•
Provide the technical resources and information to help ensure that safe water, sanitation and hygiene resources are properly installed and maintained in health care facilities.THE WORLD HEALTH ORGANIZATION WILL:
•
Provide global leadership and produce technical guidance.•
With UNICEF, report on the global status of WASH in health care facilities as part of efforts to achieve SDG 6 (ensure availability and sustainable management of water and sanitation for all) and integrate WASH and IPC within effective universal health coverage, primary health care and efforts to monitor quality of care.•
Catalyse the mobilization of resources and support the development of national business cases for WASH and IPC in health care facilities.•
Support safe WASH and basic IPC measures in health care facilities in times of crisis and humanitarian emergencies through the Health and WASH clusters.•
Report on progress in implementing the resolution to the World Health Assembly in 2021 and 2023.194
CHAPTER
2
Putting fundamentals first
Why WASH in health care facilities is still ‘non-negotiable’
WASH is essential for providing quality care and preventing avoidable deaths
Data on the extent of the problem of unsafe care reveals a shocking picture. Between 5.7 and 8.4 million people die each year in low- and middle- income countries (LMICs) as a result of poor quality care (4). An estimated 15% of patients in LMICs acquire one or more infections during a typical hospital stay (5). Infections associated with unclean
births account for 26% of neonatal deaths and 11%
of maternal mortality; together these account for more than 1 million deaths each year (6,7). In some African countries, up to 20% of women get a wound infection after a caesarean section (8,9). Sharps and needlestick injuries spread diseases including hepatitis B, C and human immunodeficiency syndrome (HIV) in health care workers, cleaners, waste handlers and others, and poor sharps waste handling is an important factor in addressing this problem (10).
KEY MESSAGES
WASH in health care is still ‘non-negotiable’ because it...
∞ is essential for providing quality care, it protects front-line health care workers, care seekers and patients and prevents avoidable deaths;
∞ is a prerequisite for infection prevention and control and preventing the spread of
antimicrobial-resistant pathogens;
∞ is fundamental for health security, preparedness and response efforts;
∞ is a necessary element of primary health care;
∞ is a human rights, dignity, social justice and gender issue;
∞ is a top priority of women receiving maternal care;
∞ is critical to ending neglected tropical diseases;
∞ is a ‘best-buy’, which makes economic sense for investment;
∞ is increasingly affected by climate change and needs climate-smart innovations and approaches;
∞ is necessary for all health- and environment-related Sustainable Development Goals.
“I remember vividly we had to take women who had just given birth to a nearby river to wash. It would take 45 minutes. Some would collapse along the way. I felt sad for them. But there was no running water at the health facility.”
Mary – a midwife from Malawi
©WaterAid/Dennis Lupenga
WASH is a prerequisite for infection prevention and
control, without which resistant microbes will continue to spread
WASH enables critical IPC practices, such as hand hygiene and environmental cleaning, which are essential to prevent the development and spread of infection, including sepsis (see Box 3), antimicrobial resistance (AMR) and outbreaks. Inadequate WASH services continue to threaten the quality and safety of care and impacts the attainment of universal health coverage (UHC), which itself aims to ensure that all people, everywhere can access the quality health services they need without incurring financial hardship. As this report highlights in Chapter 3, too many health care facilities still lack basic WASH services and therefore can neither fully protect health workers and patients, nor ensure safety and quality of care.
BOX 3. THE IMPACT OF POOR WASH AND IPC ON THE GLOBAL BURDEN OF SEPSIS
Approximately 20% of all-cause global deaths are due to sepsis: around 11 million potentially avoidable deaths. Sepsis disproportionately affects neonates, pregnant or recently pregnant women, and people living in LMICs. Sepsis mortality is often related to suboptimal quality of care, inadequate WASH and health infrastructure, poor IPC, late diagnosis and inappropriate clinical management. More than half of all cases of health care-associated sepsis are thought to be preventable through safe WASH services and appropriate IPC measures.
Sources: (11,12).
WASH is fundamental to health security, preparedness and response efforts, including for stopping the COVID-19 pandemic
Coronavirus disease (COVID-19) has further highlighted that health systems around the world remain largely underprepared and unable to respond to disease outbreaks through delivery of quality care for all, echoing past experiences with Ebola virus outbreaks. The COVID-19 pandemic has amplified the importance of WASH in health care facilities and the inequity that exists in large numbers of countries that still lack basic WASH services. It has exposed the lack of investment and highlighted the lack of WASH infrastructure, training and commitment across the world.
Data published by WHO in October 2020 (13) indicated that COVID-19 infections among health care workers are far greater than those in the general population. Globally, health care workers represent less than 3% of the population, but account for 14%
of COVID-19 cases reported to WHO. Ensuring health care workers have the basic WASH necessities to keep themselves, their co-workers, their patients and their families safe is imperative.
As with previous health emergencies, it has also highlighted that rapid change at scale is possible, at least in the short term, when the world’s attention is focused on a common issue. The present report contains multiple stories from countries where the COVID-19 outbreak has provided a catalyst for action on WASH. In Rwanda, the Government collaborated with World Vision to provide handwashing facilities in 49 hospitals, 250 health care facilities, 250 schools and 209 places of worship. In Ethiopia, a large assessment of facilities carried out as part of the COVID-19 response resulted in the mobilization of US$ 5 million to support IPC and WASH activities in 74 high-load hospitals. WHO and UNICEF launched the ‘Hand Hygiene for All’ (HH4A) global initiative in June 2020. It is a call to action for all of society to achieve universal hand hygiene and to stop the spread of COVID-19 (see Box 4).
“During these unprecedented times, it’s even more clear how fundamental WASH is for prevention of infections and improving health outcomes. We must work even closer together to ensure that WASH is included in all interventions and at scale. COVID-19 provides a new entry point to build on.”
Dr Muhammad Pate, Global Director of Health, Nutrition and Population, World Bank; Director, Global Financing Facility
BOX 4: PREVENTING COVID-19 AND SUPPORTING LASTING INFRASTRUCTURE AND BEHAVIOUR THROUGH THE
‘HAND HYGIENE FOR ALL GLOBAL INITIATIVE ’
In June 2020, WHO and UNICEF launched the Hand Hygiene for All (HH4A) Global Initiative:
a call to action for all of society to achieve universal hand hygiene and to stop the spread of COVID-19 (14). It aims to ensure all people have access to and can practice hand hygiene, including in health care facilities. The primary aim of HH4A is supporting and growing country-led efforts and investments. Additionally, it calls for countries to lay out comprehensive roadmaps that bridge national COVID-19 preparedness and response plans with mid- and long-term national development plans to ensure hand hygiene is a mainstay beyond the pandemic, again supporting overall IPC and WASH efforts.
The HH4A platform and the wide set of actors involved, from workplace/occupational health, humanitarian settings and the private sector, is a way to further support scale up of action and sustain behaviour and investments for hand hygiene. The Initiative is working to further progress access to and good hand hygiene behaviour in specific settings, such as health care facilities, schools, workplaces, transport hubs, households, and places of worship.
In health care, it builds upon and supports existing programmes such as the WHO’s global SAVE LIVES:
Clean Your Hands campaign and existing work on WASH in health care facilities.
WASH is a necessary element of primary health care
The 2018 Declaration of Astana (15) reinforced the commitment of countries to strengthen primary health care (PHC) for accelerated progress on UHC and the SDGs. The resulting draft Operational framework for PHC (16) outlines a series of actions to align health systems according to PHC principles.
The fourteen proposed actions include physical infrastructure, PHC workforce, systems for improving the quality of care and monitoring and evaluation. The framework for PHC presents opportunities to invest in and strengthen WASH as a foundational aspect of quality of care. Furthermore, WASH infrastructure in primary health care settings is less costly and easier to operate and maintain than in hospitals, allowing for more rapid and sustained improvements.
WASH is a human rights, dignity, social justice and gender issue
WASH (and waste) services serve to uphold the dignity and human rights of all care-seekers, their families and health care providers and non-clinical staff. This is especially true for vulnerable and marginalized populations, in particular mothers, newborns, children, and minorities and those living with disabilities. Frequently overlooked, but essential, aspects of care – such as receiving a glass of safe drinking-water to take medications, giving birth in a clean, welcoming room, having access to a safe and functioning and accessible toilet – all contribute to patient satisfaction, increased care-seeking and better health for all. These are all fundamental human rights (see Box 5).
Improper health care waste management can also have a negative impact on human rights (17).
Sanitation and waste services are often delivered by low status workers from marginalized sectors of society. They should be recognized as essential workers helping deliver infection prevention and control, elevating their status and offering them the same protections (such as vaccinations and personal protective equipment (PPE)) that are routinely available to health care workers (18).
BOX 5. HUMAN RIGHTS TO HEALTH AND TO WASH
The human right to health states that all individuals, without discrimination, have “the right to the highest attainable standard of physical and mental health, and to the right to life and human dignity” (UN-Human Rights Council). For a health care facility to deliver quality care it must provide safe and potable water and adequate sanitation. Efforts are underway to progressively realize the human rights to water and sanitation, which were first ratified in 2010 by focusing on reaching the underserved, addressing particular needs of women, including menstrual hygiene management, and ensuring continued access to existing WASH services (19).
Women make up 70% of the health workforce and are disproportionately impacted by unsafe working environments as front-line health workers (21).
Nurses and midwives often work at lower tier facilities that are not prioritized for improvements despite the vast majority of services taking place there. They have poorer access to water and toilets, facilities to manage menstrual hygiene needs and suffer from problems related to personal privacy, safety and security. Examples of these problems are echoed by nurses and midwives in Box 6. The 2019 GLAAS survey (1) found that two thirds of countries had clearly defined procedures for public participation in laws or policies on WASH in health care facilities.
Of these countries only 27% reported that women had high or very high levels of participation.b A new narrative is emerging that recognizes WASH in health care facilities as a social justice issue, particularly since the Resolution was passed. Social justice has been described as a matter of life and death, affecting the way people live, their chances of illness, and risk of premature death (22).
b High participation is defined as regular opportunities for stakeholders to take part in relevant policy, planning and management processes. Very high levels are defined as formal representation of stakeholders in government process contributing to joint decision-making on important issues and activities (1).
WASH is a top priority for women receiving maternal care
A 2019 survey of over 1 million women and girls in 114 countries found that of the top demands for quality reproductive and maternal health care, respectful and dignified maternity care was the most cited need, followed by WASH services and facilities (Fig. 1).
There is increasing global attention given to improving quality of care, as access to services alone has failed to reduce mortality and morbidity. The findings of the Lancet Commission on High Quality Health Systems in the SDG Era provide ample evidence to support the assertion that “providing health services without guaranteeing a minimum level of quality is ineffective, wasteful, and unethical” (23). Improving the quality of care for women and children, particularly mothers and newborns, is a critical step towards ending preventable maternal and newborn mortality and still-births, and achieving the health- related SDG targets.
BOX 6. NURSE AND MIDWIFE TESTIMONIES ON WASH SERVICE CONSTRAINTS DURING COVID-19 RESPONSE
In 2020, nurses and midwives working at the front line of the COVID-19 effort in India and Uganda described the reality of providing care with limited access to WASH services:
“There is no toilet in the health centre, it was an emergency, so I went behind the bushes. A student from a nearby school, where I give health education, saw me squatting and called me a hypocrite.”
Community health officer, India
“Menstruating in PPE is tricky, especially if you are used to heavy flow and there’s a chance you might stain your suit, as the material of our PPE is of poor quality too.
It is shameful to share these things but it is obvious, so the administrators should be sensitive! The food we were given on duty gave us diarrhoea. How do we manage that, wearing PPE?”
Nurse-in-charge, India
“Sharing toilets with men is a challenge in the rural areas, and sometimes are locked due to shortage of water. Where toilets are available, they are far and often not in the same building. Our lives are very hard!”
Midwife, Uganda
“Many have fainted after wearing PPE for a long time. We are dehydrated and not drinking enough water. Nurses are being diagnosed with urinary tract infections – it starts leaking and you want to talk about dignity!”
Nursing officer, India (tested positive for coronavirus)
Source: (20).
WASH is critical to ending neglected tropical diseases
All 20 neglected tropical diseases (NTDs) are related to WASH. For example, an estimated 43% of the schistosomiasis burden and 100% of the soil- transmitted helminth and trachoma burdens are attributed to inadequate WASH (25). Some NTDs, such as leprosy, lymphatic filariasis and mycetoma, require safe and adequate WASH for treatment and care (26).
WASH is a ‘best-buy’ which makes economic sense for investment
The Organisation for Economic Co-operation and Development (OECD) has identified interventions that – for their impact on population health, cost- effectiveness and affordability– could be defined as
‘best buys’ in tackling AMR. Improving hygiene in health care facilities, including the promotion of hand hygiene and better hospital hygiene, was one of five best buys identified. Investment in these measures could pay for themselves within just one year and produce savings of about US$ 1.5 for every dollar invested thereafter (27).
FIGURE 1. THE TOP FIVE MATERNAL AND REPRODUCTIVE HEALTH SERVICE DEMANDS OF 1.2 MILLION WOMEN
“Time and again, women said they were fed up with giving birth in dirty and disgusting conditions.
They want clean health facilities, clean toilets in maternity wards, and health providers with sterile supplies and clean hands. They want soap and water to wash themselves and their babies after birth.”
RESPECTFUL AND DIGNIFIED CARE
103 584
WATER, SANITATION AND HYGIENE
90 625
MEDICINES AND SUPPLIES
82 805
INCREASED, COMPETENT AND BETTER SUPPORTED MIDWIVES AND NURSES
65 028
INCREASED, FULLY FUNCTIONAL AND CLOSER HEALTH FACILITIES
59 388
Source: (24)“I travelled a long way from my home to seek care in a regional hospital. At the hospital I was told to soak my legs and hands in clean water for about an hour daily, and then to oil them. Otherwise the wounds will crack and become easily infected. I also need clean water and soap for dressing the affected area. This was not possible in the past when the only water source for the hospital and community was a polluted river. Thanks to WASH improvements at the hospital, I can now easily access clean water, a toilet and a shower. My artificial leg needs to be cleaned regularly so that it does not smell. This bad smell forced us not to mix with people in the past. Now we are healthy and clean and feel equal to other people.”
Leprosy patient, health care facility, Ethiopia
